GW1-2022-08833_Well Construction - GW1_20220912

VW&TO VSTRUJCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �(
4 l w L7�'() h✓�1 14.WATER ZONES
FROM TO DBSCRIMON
wanennbaemrxeme pL ft• lf)3 R /; - 1tt.IG7• f
3036,4 rR / R 3f d " Z' r— c9i
NC Well Contractor CettifiratimNsmber LS.OUTERCASING rormtlti-u wells OALWKR. rfa ties
YADION WELL COMPANY,INC. FROM To mAhorm MATZX" _1
R I
�Pm Name k6. k e e 3 3G $`/ 9- 7 o S 6.n4Pm CASING ORTORING thermal dosrd4
2.Well Construction Permit#:(ll S M 'O l tl Z 3 _ 3ko 2 Z FaOM TO Dorman Tfficm�4s MATERIAL
Lid all applicable well consimalon permits(ta UlC County,Slate,Yartanca,etc.) R 7 R t sa ,21 PV
3.Well Use(checkwell use): R ft. m
Water Supply Well: 37.SCRUN
FROM TO DIAMaTtm I SL(Yrsm I TMCXMSS i MATKRIAJ
❑Agricultural ❑ unicipal/Public
OOeotharnal(Heating/Cooling Supply) sidential Water Supply(single) R
❑lndushial/Commercial ❑Residential Water Supply(shared) IL GROUT
0hrigaton ❑Wells>100,000 OPD FROM TO MATCRIAL IMMACRAIMTMETHODRAMOUNr
Non-Water Supply Well: fe 1 R 6
❑Mmitaing ❑Recovery R tL
Injection Well: R fL
❑Aquifer Recharge ❑Oroundwmer Remediatim
19.SAMGRAVELPACKda Kunio
❑Arprifcr Storage and Recovery ❑Salinity Barrier FROM To MATsatAL EMPucesuNr 7OD
❑AquMr Test ❑Stormwahr Drainage R
❑Bxperimeatsl Technology ❑Subsidence Control R
❑Geothermal(Closed Loop) ❑Tracer 20. LOG(attach additional sheets ifnernn
DFdCRrPiION valor,hudaev saahara s' etc
❑Geothermal eating/Cooliusg Hehan) ❑Other( lain und¢#21 Remarlm) FROM I To
f� O R97 R S• rs
4.Date Well(s)Completed: a+-��` 2 Z' W�el�m##A A P-(3 7 R Z R G
5%Well Location:T. Phone fly(�y-��U�— [G�3 R
FooA cf sCu kts fYksv w(I/f✓°1/lG/ad@L R
Faatlity/OwneNeme Pecility1G#Ciifapplicable) R R LJ 1
/6 33 isuc-� Ska'Kb 2 S l� // fL
R R - - •c AUi
'rcal Addres%may,end Zip
le elk,n 2LREMARKS
County Pamelldeoli6o.ti®Na.(PIId)
5b.Latitude and longitude in degreea/minutes/semnds or decimal degrees:
(irwe0 field,one lat11ongis sufficient) 22.Certification:
IC' Q:;oXal N $(` Y4 176 W /S'-lL
6.Is(sre)theweH(s): IJPermaneat or ❑Temporary Signature of Certified Well Connector Dan
By signbrg thisform,Ihereby certify that the wells)was(were)constructed in arcoManrewith
7.Is this a repair to so erdsting well: ❑Yes or ONo 15ANCAC 02C.0100 or i3ANCAC 02C.0200 Well Construction Standards and that a ropy
lithis it a repair,fdl out brown well emsauctian brfa motion and explain the nature of the afthis record has been provided io the well owner,
repair under 42I remark section or on the back ofdtu form.
23.Site diagram or additional well details: Jo
E.For Geuprob /DFT or Closed-Loop Geothermal Wells having the as= You may are the back of this page to provide additional well construction infr
construction,only 1 0�1 is needed. indicate TOTALNUMBER of wells (add See Over'in R=mdm Box).You may also attach additional pages if necessary.
drilled, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -.7D/ (fL) Submit this GW-1 within 30 days of well completion per the following:
For mulflple went list all depths ifdfferenl(example-3@290'md2@1007
10.Static water level below top of casing: 70 (R) Ms. For All Wells: Original form to Division of Water Resources (DWR),
##'water level is above coring.we"+" Informatiou Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: CJP (In) Bd Off- , = 74b.For Infection WeBa: Copy to DWR,Underground Injection Control(fUC)
Program,1636 MSC,Ralcigb,NC 27699-1636
12.Well construction method: AIR ROTARY
24e.For Water Su 1 Md 02en-Loop Geothermal Return Welts:Copy tothe
(i.e.auger,roar),cable,disvd pub,am) county envimmnmtal health department oX the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100.000 GPD: Copy to DWR,CCPCUA
^ Permit Pgr mat,1611 MSC,Raleigh.NC 27 99-1611
13a.Yield(gpm) Method of test. / x 4J•/' �7o� p^,(•
13b.Disinfection type: 70%HTH Amount eZ 6 OZ DATE SITE VISITED: